Spontaneous remission of congenital leukemia: a case for conservative treatment

Characteristics and treatment of acute myeloid neoplasms with cutaneous involvement in infants up to 6 months of age: A retrospective study

BACKGROUND

Myeloid neoplasms account for 50% of cases of pediatric leukemias in infants. Approximately 25%-50% of patients with newborn leukemia have cutaneous extramedullary disease (EMD). In less than 10% of patients, aleukemic leukemia cutis or isolated extramedullary disease with cutaneous involvement (cEMD) occurs when skin lesions appear prior to bone marrow involvement and systemic symptoms. Interestingly, in acute myeloid leukemia with cutaneous EMD (AML-cEMD) and cEMD, spontaneous remissions have been reported.

METHOD

This is a multicentric retrospective cohort study aiming to describe characteristics, treatment, and outcome of infants with either cEMD or presence of cutaneous disease with involvement of the bone marrow (AML-cEMD). This study included patients born between 1990 and 2018 from Italy, the Netherlands, Switzerland, and the United States, diagnosed between 0 and 6 months of life with cEMD or AML-cEMD. Descriptive statistics, Fisher's exact test, Kaplan-Meier method, and log rank test were applied.

RESULTS

The cohort consisted of n = 50 patients, including 42 AML-cEMD and eight cEMD patients. The most common genetic mutation found was a KMT2A rearrangement (n = 26, 52%). Overall 5-year event-free survival (EFS) and overall survival (OS) were 66% [confidence interval (CI): 51-78] and 75% [CI: 60-85], respectively. In two patients, complete spontaneous remission occurred without any therapy. Central nervous system (CNS) involvement was found in 25% of cEMD patients. No difference in outcomes was observed between the AML-cEMD and cEMD groups, but none of the latter patients included in the study died. KMT2A rearrangements were not associated with poorer prognosis.

CONCLUSION

In the largest cohort to date, our study describes the characteristics of infants with cutaneous involvement of myeloid neoplasms including cytomolecular findings and survival rates. Further prospective biologic and clinical studies of these infants with myeloid neoplasms will be required to individualize therapy for this rare patient population.

Aleukemic congenital leukemia cutis preceding monocytic leukemia with favorable outcome: A case report

A newborn girl had typical "blueberry muffin" skin lesions, which shows histopathologic features of monocytic leukemia cutis. The systemic leukemia was demonstrated after one month of life. She was treated by chemotherapy, including induction and three consolidation cures, according to the ELAM02 protocol, which led to complete remission. This case report with congenital form of AML5 cutaneous localization, preceding systemic involvement, with a 5-year follow-up and positive outcome is remarkable.

Congenital Acute Myeloid Leukemia with Unique Translocation t(11;19)(q23;p13.3)

Congenital leukemia is rarely encountered in clinical practice, even in tertiary children's hospitals. Leukemia may cause significant coagulopathy, putting the patient at risk of intracranial hemorrhage. In this case, the authors present a female infant with a unique mixed phenotypic congenital acute myeloid leukemia showing mixed-lineage leukemia (MLL) rearrangement and severe coagulopathy resulting in a large subdural hematoma. Despite the fatal outcome in this case, neurosurgical treatment of patients with acute myeloid leukemia should be considered if coagulopathy and the clinical scenario allow.

Neonatal leukaemia cutis

Neonatal leukaemia cutis is a significant neoplasm that may represent a cutaneous manifestation of systemic leukaemia, usually of myeloblastic type. Rarely, it may be or appear to be limited to skin, in which case it is called neonatal aleukaemic leukaemia cutis. By definition, it presents within the first 4 weeks of life and often has a 'blueberry muffin baby' appearance of magenta coloured nodules affecting almost any area of the skin, usually sparing mucous membranes, palms and soles. This clinical pattern is more commonly associated with neonatal infections such rubella and toxoplasmosis, and may be evident with other neonatal neoplasms such as neuroblastoma. Due to the morbidity associated with chemotherapy and reported cases of spontaneous remission without systemic progression in those with neonatal aleukaemic leukaemia cutis without 11q23 translocation, the authors not treating the child with chemotherapy, but to simply monitor for fading of the violaceous nodules, and watch for possible signs of systemic leukaemia.

Congenital leukemia of fetus with acquired AML1 gene duplication

Congenital leukemia is very rare, and its prevalence according to recently published papers is from 1 to 5 per million live births. This can be often diagnosed in postpartum throughout bone marrow biopsy, showing abnormal proliferation of immature blasts and granulocytic precursors. Hepatosplenomegaly is the most common feature which is found during perinatal examinations, that diagnosing is difficult during perinatal period. Hepatosplenomegaly can occur not only in congenital leukemia but in many other cases such as infection which is the most common cause. In other words, congenital leukemia is the one of the rare causes of hepatosplenomegaly. However, this case shows the fetus with the features of hepatosplenomegaly during perinatal period and being diagnosed as congenital leukemia associated with acquired AML1 gene duplication in postpartum through bone marrow biopsy. Due to its rare instance, we are to describe the case with a review of literatures.

A 7-week-old boy with violaceous patches and skin nodules. Leukemia cutis

A 7-week-old boy presented to the pediatric dermatology clinic for evaluation of diffuse blue lesions on the skin. The mother first noticed a bluish lesion on the left thigh at 6 to 7 weeks of age. The child quickly developed several similar lesions and deeper nodules on the head, arms, and trunk. He had a history of ankyloglossia and subsequent uncomplicated repair, as well as a sister with neonatal anemia. He was otherwise well and thriving. Review of systems was unremarkable. His birth involved an uncomplicated delivery, with negative maternal serology. There was no history of maternal infection or recent exposure to infection. Physical exam revealed a well-appearing, non-dysmorphic, vigorous infant. Skin exam was notable for numerous dusky erythematous and violaceous-blue patches and nodules on the anterior scalp, bilateral arms, legs, face, and trunk - including the diaper area. Lesions ranged in size from 1 to 3 cm. The nodules were firm and non-tender. The remainder of his physical examination was normal without abnormal lymphadenopathy or hepatosplenomegaly noted. No mucosal lesions were noted. A biopsy was performed on a thigh lesion.

Congenital papulonodular eruption: presenting sign of congenital leukaemia cutis

Congenital leukaemia (CL) is a rare malignancy that accounts for < 1% of cases of childhood leukaemias. Leukaemia cutis (LC) refers to cutaneous infiltration with leukaemic cells, and is seen in 30-50% of CL cases. It may precede, follow or occur simultaneously with leukaemia. If left untreated, the prognosis is usually poor, but early diagnosis and treatment may result in a favourable prognosis. We report a case of congenital leukaemia cutis with a progressive, violaceous papulonodular eruption (a 'blueberry muffin' rash), which had been noted at birth, as a presenting sign of acute myeloid leukaemia (AML), which on investigation was classified as AML, FAB M2 type with a t(8; 21)(p11;q22) chromosomal defect. The patient had a favourable response to AML chemotherapy.

Siblings presenting with progressive congenital aleukemic leukemia cutis

Congenital leukemia is infrequent, occurring in <1% of pediatric leukemia patients, and mainly of myeloid lineage. Twenty-five to 30% of congenital leukemia cases present with cutaneous leukemic infiltrates. Rarely, infants will have aleukemic leukemia cutis, presenting with leukemic skin lesions but without systemic symptoms or bone marrow involvement. Few cases of congenital aleukemic leukemia cutis have been reported in the literature. The course of disease is variable as cases of spontaneous resolution have been described. Here we present the first report of siblings with progressive congenital aleukemic leukemia cutis, both treated successfully with myeloid leukemia chemotherapy.

Congenital acute myeloid leukemia with t(8;16) and t(17;19) double translocation: case presentation and literature review

Congenital leukemia is uncommon and excluding transient myeloproliferation associated with Down syndrome, makes up approximately 1% of childhood leukemias. A newborn boy was born with multiple subcutaneous nodules and large purpuric papules. Skin biopsy revealed proliferation of atypical hematologic cells in the dermis. Bone marrow morphology was consistent with acute myeloid leukemia (M5) and cytogenetic studies revealed t(8;16) and t(17;19) double translocation. Although prognosis of congenital leukemia is known to be dismal, recent reports showed spontaneous remissions. With the fear of chemotherapy-related toxicity, to treat or not to treat may be a dilemma both to parents and pediatricians. We report our experience and review the literature.

A case of congenital leukemia cutis

Congenital leukemia is a rare disease that develops from birth to 6 weeks of life. Leukemia cutis involves cutaneous infiltration by leukemic cells and is an unusual manifestation of leukemia, and has been documented in 25~30% of patients with congenital leukemia. The authors report a case of congenital leukemia cutis. A newborn male presented with widespread firm dusky red papules and nodules on almost his entire body surface. Skin biopsy specimens confirmed the presence of leukemic infiltrations, and bone marrow cytology was consistent with acute myeloid leukemia of the FAB M5 type.

Pancreatic panniculitis caused by L-asparaginase induced acute pancreatitis in a child with acute lymphoblastic leukemia

Panniculitis caused by L-asparaginase induced acute pancreatitis is an unusual condition. We report a case of a 7-year-old Thai boy with underlying acute lymphoblastic leukemia who developed pancreatic panniculitis caused by L-asparaginase administration. During the second week of induction chemotherapy, the patient developed acute pancreatitis with septic shock. Two weeks later he developed multiple subcutaneous nodules on the abdominal wall. Skin excisional biopsy showed the typical histopathological features of pancreatic panniculitis. Acute pancreatitis improved after 3 weeks of conservative treatment. The skin lesions resolved spontaneously within 1 month.

[Blueberry Muffin Baby and spontaneous remission of neonatal leukaemia]

Blueberry Muffin baby is a rare neonatal skin disorder. Many causes are known, examples are congenital infections, hemolysis and tumors. We report on a newborn presenting with Blueberry Muffin syndrome and an adrenal mass which lead to the diagnosis of neuroblastoma. Actually, it corresponded to an acute monoblastic leukaemia with an adrenal localization and a cerebrospinal fluid involvement. Leukaemia should always be considered in such patients, even in the absence of blasts on white blood cells count and bone marrow examination, as in this patient. This observation was also unusual due to spontaneous remission. The patient is in complete remission at 1 year follow-up.

Spontaneous resolution of a single lesion of myeloid leukemia cutis in an infant: case report and discussion

Though infantile leukemia has a historically poor prognosis, there may be a subset of patients with cutaneous disease whose disease will resolve without therapy. The authors report a case of infantile leukemia cutis who presented with a single subcutaneous chloroma that spontaneously resolved over the course of several weeks and who remains without evidence of disease nearly two years later. After reviewing the literature of congenital leukemia cutis, the authors conclude that withholding chemotherapy in infants with cutaneous myeloid leukemia in the absence of known negative prognostic factors (MLL or BCR-ABL translocations) or progressive disease is clinically indicated.

Congenital leukemia cutis with subsequent development of leukemia

We describe a newborn infant who was born with a purpuric rash and subcutaneous nodules. Skin biopsies demonstrated acute myeloid leukemia. Cytogenetic studies revealed an 11q23 rearrangement. Initial bone marrow and cerebrospinal fluid examination did not demonstrate medullary or meningeal disease. Chemotherapy was initiated on the basis of the abnormal cytogenetic findings in the skin biopsy. Intensive chemotherapy was, given but the infant's leukemia progressed. The patient died of refractory leukemia and secondary fungal disease. This case report supports the observation that leukemia cutis with an 11q23 rearrangement should be treated aggressively.

Testicular chloroma in a nonleukemic infant

Extramedullary myeloid cell tumors (EMCT) are localized collections of immature myeloid cells that occur outside of the bone marrow. Usually observed concurrently with bone marrow disease, EMCT also may occur in the absence of overt marrow leukemia. In this report, we describe an infant with a testicular mass that was identified as an EMCT after orchiectomy. Unlike the only previously reported case of infantile testicular chloroma, this patient did not exhibit bone marrow disease at diagnosis. Because systemic chemotherapy is considered to be superior to local control (surgery, radiation therapy), the patient was treated with intensively timed induction chemotherapy followed by 3 cycles of maintenance treatment (according to CCG protocol #2891) but no radiation therapy. The patient remains disease-free 18 months after diagnosis.

Spontaneous regression of aleukemia congenital leukemia cutis

A full-term 2-week-old boy was referred to the pediatric dermatology clinic with numerous blue to violaceous nodules present since birth. TORCH titers (against toxoplasmosis, cytomegalovirus, herpes simplex virus, rubella, and syphilis) were negative. Complete blood count and peripheral smear were normal. A skin biopsy specimen showed an atypical cellular infiltrate suspicious for leukemia or lymphoma. A bone marrow biopsy specimen demonstrated acute myelogenous leukemia (M4 subtype). Following consultation with pediatric oncology and the recognition of the potential for spontaneous regression, chemotherapy for the infant's condition was not recommended. He remained otherwise healthy and was followed-up with biweekly to monthly complete blood counts and physical examinations, which were repeatedly normal. By 3 months of age, the nodules had completely resolved and there was no evidence of recurrence at 8 months of follow-up. We report this instance of aleukemic congenital leukemia with spontaneous regression of leukemia cutis without therapeutic intervention.

Aleukemic congenital leukemia cutis

A newborn girl had typical "blueberry muffin" skin lesions, which showed histopathologic features of myelomonocytic leukemia cutis. We could not demonstrate leukemic infiltration of bone marrow in four aspirates. Her course was complicated with primary pulmonary hypertension, which led to death at 7 months of age. We emphasize the persistence of skin lesions in the absence of bone marrow infiltration by leukemia throughout the course of the disease.

Bone marrow evaluation in pediatric patients

Pediatric bone marrow evaluation is often challenging, especially for pathologists with more experience evaluating bone marrow specimens from adults. This article reviews the features of several pediatric hematologic malignancies that have been selected because they illustrate the different approach required to evaluate pediatric bone marrow specimens, and highlight potential diagnostic pitfalls. The following topics have been selected for discussion: ancillary studies required for prognostication in pediatric acute lymphoblastic leukemia, the classification of pediatric acute myeloid leukemia, congenital acute leukemia and its distinction from Down syndrome-associated transient myeloproliferative disorder, diagnosis and classification of pediatric myelodysplastic syndromes, and juvenile myelomonocytic leukemia as a distinct disease entity of childhood.

Fetal and neonatal leukemia

The biological and clinical characteristics of perinatal leukemia differ significantly from those of leukemia in older children, and the prognosis is generally bleak. Once complete remission is achieved, neonates with acute myelocytic leukemia (AML) fare much better than those with acute lymphocytic leukemia (ALL). The results of this study suggest that age, sex, type of leukemia, and cytogenetic findings have a strong influence on outcome. Neonates, particularly females, with pre-B ALL have a much worse prognosis than neonates and older children with this disease. Transient leukemia in the Down syndrome neonate is associated with significant morbidity; close follow-up is recommended for at least the first 3 years of life because of the potential of developing acute leukemia, particularly AMKL (M7). The purpose of this review is to focus on the fetus and neonate in an attempt to determine the various ways leukemia differs clinically and morphologically from the disease occurring in older infants and children and to demonstrate that certain types of leukemia have a poor prognosis compared with those occurring in older children.

Is t(10;11)(p11.2;q23) involving MLL and ABI-1 genes associated with congenital acute monocytic leukemia?

Congenital, or perinatal, leukemias are rarely observed, but retrospective molecular studies seem to suggest a more frequent onset in prenatal life. Myelocytic types are common, and chromosome band 11q23 rearrangements at the MLL locus are characteristic genetic markers. The fusion of the MLL gene with one of its partners, ABI-1, has recently been described in two infant leukemia patients with monocytic involvement and good clinical outcome. We report a case of congenital monocytic leukemia with the same gene involvement and good response to chemotherapy. The blast metaphases were probed by fluorescence in situ hybridization, and t(10;11)(p11.2;q23) involving MLL and ABI-1 genes was demonstrated with the same breakpoint in ABI-1. The congenital presentation of this case suggests a possible relationship of this genetic event with in utero leukemogenesis.

[Cutaneous symptoms revealing a monoblastic leukemia]

Leukemia cutis (LC) are not rare in acute myeloid leukaemia (AML) in children but exceptionally reveal it. Most authors think that they have poor prognosis.

CASE REPORT

We report the case of an infant with isolated cutaneous involvement at the time of diagnosis of leukaemia. Bone marrow aspiration showed AML M5. The child was treated by LAME 91 protocol, arm "infant under one year of age". Complete remission, both in bone marrow and skin, was obtained after induction course. Then the patient received consolidation course and megatherapy followed by autologous bone marrow transplantation. Skin relapse occurred early. The complete remission no. 2 was not obtained by second line treatment: new LC appeared when PMN count increased more than 10(9)/l. Then, the child was treated with oral VP16 but disease progressed with more and more LC, followed by bone marrow relapse. Child's death occurred about one year after diagnosis.

Isolated myelosarcoma in children--update and review

Primary myelosarcomas, also called leukemia cutis, granulocytic sarcomas or chloromas, are rare extramedullary manifestations of acute myeloid leukemia (AML) which precede bone marrow involvement. Skin infiltration was the most frequent localization associated with a myelomonocytic differentiation. Although first remission was achieved by most children, risk of relapse seemed to be increased. This might be caused by the specific biology of myelosarcomas, but also may be the result of delayed or reduced treatment. During the AML-BFM-studies 87/93/98 (11/1987-7/2000) 37 children with isolated myelosarcomas were diagnosed. Eighteen of the 37 patients survived with a 5-year overall survival estimation of 0.54+/-0.09 compared to 0.59+/-0.02; p(log rank) = 0.94. However, reduced or delayed treatment in 17 children led to an increased relapse rate of 71% compared to 35% in children treated soon after diagnosis. The 5-year overall survival in these patients was 0.41+/-0.11. According to our experience and review of the literature, an early diagnostic workup is needed in children with unusual skin lesions or tumors, considering myelosarcoma as primary manifestation of AML. Intensive AML-specific chemotherapy is generally recommended soon after diagnosis.